Your First Visit

Patient Registration

New Patients
Schedule Your Consultation Today!

Online Payment Form

Online Payment Form - Authorize.net

Patient Name*
First Last
Patient ID / Account Number*

PLEASE ENTER 6 DIGITS (Having issues with your ID number? Please call the office you were seen at.)
Patient Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Payment Amount*
Name on Credit Card*
First Last
Credit Card Billing Address*
Street Address Address Line 2 City State ZIP Code
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
(Please only click Submit once to avoid multiple transactions.)
Total
$0.00
Address
This field is for validation purposes and should be left unchanged.

Learn more

Watch Our Video to Hear from the Professionals.

Our Offices

Warren / Sterling Heights Office

Address

29427 Ryan Rd.

Warren, MI 48092

Phone 586-755-9340

FAX 586-755-1081

Email

[email protected]

Grosse Pointe Woods / Detroit Office

Address

20675 Mack Ave.

Grosse Pointe Woods, MI 48236

Phone 313-885-8344

FAX 313-885-1819

Email

[email protected]

Rochester Hills / Troy Office

Address

305 Barclay Circle Suite 1000

Rochester Hills, MI 48307

Phone 248-293-5500

FAX 248-293-5505

Email

[email protected]

Macomb / Clinton Township Office

Address

15286 Wellington Center Blvd.

Macomb, MI 48044

Phone 586-286-1600

FAX 586-286-8963

Email

[email protected]

Romeo / Washington Office

Address

12150 30 Mile Rd. Suite 202

Washington, MI 48095

Phone 586-752-9691

FAX 586-752-6199

Email

[email protected]

New Baltimore / Chesterfield Office

Address

35050 23 Mile Road, Suite C

New Baltimore, MI 48047

Phone 586-725-2400

FAX 586-725-2405

Email

[email protected]

Dental Website Design by PBHS © 2025 • Non-Discrimination Notice